Before providing a service on the Advance Notification/Prior Authorization List, the facility must confirm coverage approval is on file. This promotes an informed pre-service discussion between the facility and member. If the service is not covered, the member can decide whether to receive and pay for the service.
If the facility performs the service without confirming a coverage approval is on file, and we decide the service is not a covered benefit, we may deny the facility claim.
The facility may not bill the member or accept payment from the member due to the facility’s non-compliance with our notification protocols.
Some benefit plans may have separate notification or prior authorization requirements. Refer to the Benefit plans subject to this guide table in Chapter 1: Introduction and to the supplements of this guide for additional information for the plans listed.
Facilities are responsible for admission notification for the following inpatient admissions. We need admission notification, even if the physician provided advance notification and pre-service coverage approval is on file:
Weekday admissions, you must notify us within 24 hours, unless otherwise indicated.
Weekend and holiday admissions, you must notify us by 5 p.m. local time on the next business day.
Emergency admissions (when a member is unstable and not capable of providing coverage information), you must:
Payment is not reduced due to notification delay in an emergency.
Receipt of an admission notification does not ensure payment. Payment for covered services depends on the member’s benefits, facility’s contract, claim processing requirements, and eligibility for payment.
You must include these details in your admission notification:
All SNF admissions for UnitedHealthcare Nursing Home and Assisted Living plan members must be authorized by an Optum nurse practitioner or physician’s assistant. Claims may be denied if authorizations are not coordinated through Optum.
Hospitals must notify us of discharge from acute facility stays within 24 hours after weekday discharge (or by 5 p.m. local time on the next business day if the 24-hour limit would require notification on a weekend or holiday). For weekend and holiday discharges, we must receive the notification by 5 p.m. local time on the next business day.
Decisions regarding whether services met the definition of an “emergency” may be made by our Medical Director (or designee) or another process. This determination is subject to appeal. You can find a definition of “emergency” in the Glossary.
Facilities must provide timely admission notification (even if the physician provided advance notification and pre-service coverage approval is on file) as follows or claims payments are denied in full or in part:
|Notification time frame||Reimbursement reduction|
|Admission notification received after it was due, but not more than 72 hours after admission.||100% of the average daily contract rate1 for the days preceding notification.|
|Admission notification received after it was due, and more than 72 hours after admission.||100% of the contract rate (entire stay).|
|No admission notification received.||100% of the contract rate (entire stay).|
If advance notification or prior authorization is required for an elective inpatient procedure, the physician must get the approval. The facility must notify us within 24 hours (or the following business day if the admission occurs on a weekend or holiday) of the elective admission. If the physician gets the approval, but the facility does not get theirs within a timely manner, we reduce payment to only room and board charges.
If the physician received coverage approval, we pay the initial day of the inpatient admission unless any of the following are true:
We determine the medical necessity of inpatient admissions during either concurrent or retrospective review. We require you to comply with our requests:
We issue a denial letter if the level of care or any inpatient bed days are not medically necessary. We decide this through concurrent or retrospective review. We use nationally recognized criteria and guidelines to determine if the service/care was medically necessary under the member’s benefit plan. We can provide the criteria to you upon request.
A facility denial letter is sent to the member and copied to the admitting physician, the PCP (if applicable) and the facility, as required.